2

“Most people think that the Asian community is prosperous. But the majority of our people are , middle class and low-income. The State of Chinese Health will bring attention to the social issues and healthcare needs of our community. Chinese Americans are often misunderstood; it is important to for us to be understood.”

— Henry Chen, MD, President of SOMOS

6 7

MISUNDERSTOOD THE STATE OF CHINESE HEALTH IN NEW YORK 10 MISUNDERSTOOD THE STATE OF CHINESE HEALTH IN

New York City is home to the largest Chinese population with the doctors that serve Chinese New Yorkers, as well outside of Asia. Today, the greater New York metropolitan as existing research and public data. In Chinese, there is an area boasts over 800,000 Chinese residents—16% of expression of “simplifying what is complicated” ( 化繁為簡). the entire US Chinese population.1 The city’s numerous Through The State of Chinese Health in New York City, we Chinatowns continue to be a thriving and vital part of the strive to untangle the web of misperceptions that adversely community, fueled by constant flows of immigration. impact Chinese New Yorkers’ health so that we can get to a place of harmony, balance, and good health. In the bustling streets of ’s Chinatown or ’s Sunset Park, the Chinese knot—which through This study is part of SOMOS’ broader effort to gain a its symmetry and feng shui, symbolizes good fortune comprehensive understanding of the general state of health and health—commonly hangs on lampposts, awnings, of the populations we serve throughout New York City. and doorways. Yet, despite the ubiquity of the symbol, SOMOS is a non-profit, physician-led network of nearly the health of Chinese New Yorkers can be described as 3,500 community health providers in , Brooklyn, anything but harmonious. Even with their rapidly growing , and Manhattan, serving primarily immigrant and evolving presence, the Chinese community’s diversity communities of all ethnicities and ages—200,000 of whom and unique cultural challenges are often overlooked, are Chinese. oversimplified, and misunderstood. This belies the real The State of Chinese Health in New York City serves as a roadblocks they face relating to fundamental needs—the companion piece to The State of Latino Health in New York most important of all being their health. City. Similar to The State of Latino Health in New York City, This report aims to fill in this knowledge gap. Our research our goal is to inform key stakeholders and policymakers includes a first-of-its-kind, city-wide survey and in-depth at the city, state, and federal level of the challenges that interviews of Chinese New Yorkers, both of which were Chinese New Yorkers face. We hope this report will help conducted in Chinese, allowing our Chinese respondents identify solutions that will improve access to healthcare and to answer in the comfort of their own language and in their promote a greater quality of life for Chinese New Yorkers own homes. Our study integrates the conversations we had and the vibrant communities in which we live.

11 BUILDING THE CASE FOR MORE CULTURALLY-RICH HEALTH RESOURCES AND DELIVERY OF CARE

Despite its rapid population growth and having a rich, In-depth interviews of Chinese patients and a focus group centuries-old history of living and working in New York City, with their doctors reveal how cultural misunderstanding the Chinese community is one of the most vulnerable and often leads to lack of compliance with medical advice, underserved segments in the city. Nearly 20% live under the denial of illness, and overall misalignment between doctor poverty line, a third lack citizenship, and nearly two-thirds and patient. deal with language barriers.2 This serves as important 3. Despite being underserved and lacking sufficient context to understanding their general state of health. culturally-relevant health resources, ideal health conditions Our key findings include: for Chinese New Yorkers are within reach. 1. Chinese New Yorkers are not as healthy as they think • Over 90% have healthcare insurance they are. Nearly 80% believe they are in good health and • 70% have a Chinese-speaking primary doctor have a healthy lifestyle—and yet: • 65% of Chinese New Yorkers visit their primary • 70% report that they have been diagnosed with a health care doctors often condition, with a sizable number having hypertension, • Over 50% have a positive outlook on the depression, and diabetes healthcare system • Only 52% say they don’t smoke Chinese New Yorkers who behave and feel this way • Only 43% say they watch their diet carefully generally have access to more resources such as established This contradiction strongly suggests Chinese New Yorkers in-language community support, a Chinese-speaking are downplaying their conditions—likely resulting in more primary doctor, and cost-effective care. Increasing these fatal conditions in the future. Indeed, lung cancer, heart factors can tip the scales from being a community rife with disease, diabetes, and suicide fall within the top 10 causes misperceptions and disparities to a model of great health. of mortality for Chinese New Yorkers.

2. Communication issues are an enormous health barrier, but it goes beyond speaking the same language. For health providers, it’s also about being fluent in their culture. For Research Methodology: Chinese New Yorkers, it’s about being health literate. • City-wide survey of 300 respondents that represent the • Over 60% have limited English proficiency demographic profile of the Chinese population living in New York City (conducted in Chinese and English) • 54% say most healthcare providers do not share their culture • In-depth interviews of four low-income, Chinese-language dependent Chinese residents to gain deeper insights from • 50% say they still don’t understand what their doctors at-risk, harder-to-reach patients (conducted in Mandarin) are saying even when the doctors speak Chinese • Focus group of 10 doctors that serve Chinese communities in New York City

12 13

CHINESE NEW YORK UNDERSTANDING A GROWING, BUT VULNERABLE COMMUNITY CHINESE NEW YORK UNDERSTANDING A GROWING, BUT VULNERABLE COMMUNITY

Coined in the 1960s, the term “model minority” was used the greater Flushing area as Mandarin was the lingua franca. to describe Chinese and other Asian Americans as a More affluent segments crossed the Queens border to well-educated, healthy, and prosperous group with fewer Nassau County. problems to be addressed. While the “Model Minority Myth” Sunset Park, Brooklyn is often referred to as “Little ” has since been debunked countless times by social scientists for its large population of Fuzhounese immigrants who and activists, it remains a persistent and injurious trope. sought more affordable housing compared to what existed This section aims to provide a nuanced portrait of Chinese in Manhattan’s Chinatown area. A large number are New Yorkers to fully understand and unpack their health undocumented and are employed in low-paying occupations. challenges and needs. The Chinese population has since expanded across the southern part of Brooklyn, from Bay Ridge to Coney Island.3

A PATCHWORK OF New York’s Chinatowns continue to be vibrant, ever-evolving CHINESE IMMIGRATION communities, extending well past their original borders and The diversity of the Chinese population in New York can giving rise to new satellite Chinatowns nearby ( Figure 1 ). be understood through the ’s Figure 1. New York’s Official and Unofficial Chinatowns Chinatowns. In the late 19th Century, Chinese immigrants trickled slowly into following growing anti- Chinese sentiment and the decline of mining in the Western BRONX states. The anti-Chinese sentiment culminated with the 1882 Elmhurst Flushing Bayside and Little Neck Chinese Exclusion Act, which was not lifted entirely until the MANHATTAN passing of the 1965 Immigration and Naturalization Act.

Chinatown Forest Hills Following the 1965 Act, Manhattan’s Chinatown saw an influx QUEENS of Chinese immigrants, mainly Cantonese speakers from BROOKLYN

Hong Kong and Guangdong Province. The post-1965 period Sunset Park also brought in a large number of Taiwanese immigrants, STATEN ISLAND who mainly spoke Mandarin and had the benefit of higher Bensonhurt educational and socioeconomic status. Having little in Homecrest common with their Manhattan counterparts, they chose Flushing, Queens as their home. Later and larger waves Source: Stephanie Tuder, “Believe it or not, New York City has Nine Chinatowns” Eater New York, February 25, 2019; Matthew Bloch, et. al, “Mapping Segregation,” coming from Mainland also opted to settle around New York Times, July 8, 2015

16 17 A GROWING BUT VULNERABLE MARKET

Today, at an estimated 661,854 living in New York City Limits, Based on 2017 US Census estimates, nearly 20% of Chinese the Chinese population is the fastest growing segment in New Yorkers fall below the poverty line. Among those aged New York City, growing by 50% since 2005 ( Table 1 ). 65 and above, the percent impoverished jumps to 30% The Chinese segment is also the largest Asian group in the compared to 18% for the elderly in New York City overall city, making up about half of the Asian population in New ( Figure 2 ). The neighborhoods with the largest Chinese York City.4 populations have higher poverty levels: the poverty rate in Manhattan’s Chinatown is 28% and the poverty rate in Statewide, Chinese New Yorkers have $16.4 billion in Brooklyn’s Sunset Park is 26%—both well over New York spending power and contribute $2.6 billion in state and City’s poverty rate of 21% ( Table 2 ). Moreover, about local taxes.5 In aggregate, Chinese New Yorkers’ wealth two-thirds lack English proficiency and a third of the Chinese appears to be just below that of New Yorkers overall. In 2017, population in New York lack US citizenship ( Figure 3 ). the average per capita income for Chinese New Yorkers is estimated at $30,565, compared to New York’s overall per Being low-income, having poor English fluency, and capita of $35,761. Yet, amid their growing influence, a closer lacking citizenship are not positive social determinants of examination reveals considerable disparities. health. The bottom line? We are far from the prosperous “model minority”.

Table 1. Chinese Population Growth by Borough, 2017 Table 2. Household Income and Poverty Rate by Borough, 2017

Percent of Total % Pop. Change Area Population Population from 2005 Area Median HH Income Poverty Rate

New York City 661,854 7.3% +48.7% New York City (city limits) $60,879 21% (city limits)

Bronx 7,003 0.5% -1.87% Chinatown, Manhattan $43,316 28%

Brooklyn 215,427 8.1% +48.0% Flushing, Murray Hill $51,284 16.2% & Whitestone Manhattan 120,670 7.2% +24.7%

Sunset Park, Brooklyn $47,970 26% Queens 262,592 11.1% +52.8%

Source: US Census Bureau, 2017 American Community Survey, New York City Limits; Staten Island 23,071 4.8% +88.1% Census Reporter Profile Page for NYC—District 7 PUMA and District 3 PUMA; An economic snapshot of the Greater Sunset Park Area, Office of the New York State Source: US Census Bureau, 2017 American Community Survey, New York City Limits Comptroller, 2016

18 Figure 2. Poverty Level of Chinese New Yorkers, 2017

Chinese in NY NYC Overall US Overall

% in Poverty % in Poverty 65+

18% 30.3%

19.6% 18%

13.4% 9.3%

Source: US Census Bureau, 2017 American Community Survey, 1-Year Estimates, Chinese alone or in combination, New York City Limits

Figure 3. Nativity of Chinese New York Population, 2017

Foreign Born, Naturalized 37%

US Born 30%

Foreign Born, not a US citizen 32%

Source: US Census Bureau, 2017 American Community Survey, New York City Limits

19 THE PROBLEM WITH DATA

Funding to support Chinese communities continue to fall significantly short. According to the Asian American Federation, the Asian Pacific Islander ( API ) community received 1.4% of the total dollar value of New York City’s social service contracts from fiscal year 2002 through 2014—despite the fact that the API community represents 13.5% of the city’s total population.6

This is due in large part to data, from how it is collected to how it is analyzed, as it dictates how resources are distributed. Specific ways in which data has been problematic include:

• Aggregated data: According to Pew Research Center, the US Asian population is incredibly diverse and the most economically divided group in the US.7 In New York City, vast income disparities exist among the Chinese population—not just across Asian ethnicities. Yet, when viewed in aggregate, Chinese New Yorkers appear to be nearly on par with non-Hispanic whites, resulting in fewer resources allocated to social services at the local, state, and federal levels. • Language challenges: The Asian population is predominantly foreign-born and in-language dependent. Among the Chinese population in New York, a whopping 61% have Limited English Proficiency( LEP). However, research is often conducted in English, skewing the respondent base towards those who may have a better quality of life. • Complexity: The complexity of the API landscape, coupled with the relatively small size of the population, deter researchers from diving deep into the community, resulting in a dearth of information when compared to other racial/ethnic groups.

The lack of accurate and robust data collected on API groups is a pervasive challenge and helps to inform why Chinese New Yorkers are often overlooked and misunderstood.

20 21

WHAT AILS US WHAT AILS US

PERCEPTION VERSUS REALITY: Indeed, when asked about their behaviors and lifestyle WE ARE NOT AS HEALTHY AS WE THINK habits, Chinese New Yorkers’ responses concur more so with their doctors’ assessment. Nearly half indicate they SOMOS’ citywide survey of 300 Chinese New Yorkers found smoke, 47% don’t exercise regularly, 55% don’t follow health that 80% of Chinese New Yorkers believe they are “in good professionals’ advice, and nearly 60% don’t watch their diet health” and “have a healthy lifestyle” ( Figure 4). carefully ( Figure 5).

However, based on focus groups with the doctors serving Chinese patients, Chinese New Yorkers could be healthier. WHAT REALLY AILS US? Doctors say that members of the Chinese community have a Moreover, in contrast to what Chinese New Yorkers think, false sense of security regarding their health as many of their 70% self-reported that they have been diagnosed with a conditions go undetected, especially diabetes, hypertension, medical condition. Just as their doctors say, hypertension, and Hepatitis B.8 depression and diabetes rank high on the list ( Figure 6).

Figure 4. Perceived Health Status

Would you consider that in general your health is? Do you have a healthy lifestyle?

Good Healthy 67% 64%

Not sure 5%

Not sure Fair 12% 16%

Very healthy 15% Very good Poor Not very healthy 11% 1% 9%

Source: SOMOS Health Survey of Chinese New Yorkers

24 Figure 5. Participation in Healthy Lifestyle Habits

Yes No

I exercise regularly 53% 47%

I do not smoke 52% 48%

I follow health professionals’ advice 45% 55%

I rarely consume alcohol 44% 56%

I actively seek health info 44% 56%

I watch my diet carefully 43% 57%

I have an active social life 39% 61%

Source: SOMOS Health Survey of Chinese New Yorkers

Figure 6. Diagnoses Received

Type of Diagnosis

Have you been diagnosed with a High blood pressure/Hypertension 18% medical condition in the last 5 years? Depression 11%

Arthritis 10%

Asthma 9% Yes 70% Anxiety 8%

Diabetes 8%

Obesity 7%

Insomnia 6%

Cardiovascular Disease 6% No 30% High Cholesterol 4%

Hepatitis B/C 3%

None 30%

Source: SOMOS Health Survey of Chinese New Yorkers

25 LUNG CANCER WE STILL SMOKE

Cancer is the leading cause of death among Chinese New The five leading cancers for the Chinese community in New Yorkers. In fact, Asian Americans are the only segment that York City, in rank order, are lung, colorectal, liver, stomach, have cancer as the leading cause of death, both in New York and breast cancer. The lung cancer mortality rate among the City and in the nation.9 Suicide is ranked 9th out of the top Chinese New York population is 32.1 per 100,000 population, 10 causes, which is not on the list for New York City overall— an increase of 70% from 2000 to 2014. During this same time strongly indicating that mental health support is needed for period, the rate for New York City overall decreased the Chinese New York community ( Table 3 ). by 16.4%.10

That Chinese New Yorkers believe they are healthy in spite of Based on the SOMOS Chinese Health Survey, only 52% of their diagnoses suggests they are not taking their conditions Chinese New Yorkers report to abstain from . This seriously and remain untreated. suggests that 48% may smoke on some level, with higher numbers living in Brooklyn and Manhattan—where their communities of Sunset Park and Chinatown tend to be Table 3. Leading Causes of Death among poorer and where lung cancer is the top cause of premature Chinese Americans in New York City, 2014 death ( Figure 7 ).11

Rank Chinese in NY NYC Overall Chinese men who live in New York City are more likely to smoke and die from lung cancer than their female 1 Cancer 33% Heart Disease 31.1% counterparts. According to the 2013-2015 New York City

2 Heart disease 23.9% Cancer 25.2% Community Health Survey, 27% of Chinese men are current smokers, which is nearly double the percentage for New

3 Stroke 5.3% Flu/pneumonia 4.2% Yorkers overall at 15% and seven times more than Chinese women at 4%.12 Likewise, for New York City, the lung cancer Lower respiratory diseases Flu/pneumonia 4.9% 4 3.4% death rate for Chinese men is 45.5 per 100,000 versus 21.0

Lower respiratory per 100,000 for Chinese women.¹³ 5 Diabetes 3.4% diseases 3.9%

6 Accidents 2.9% Stroke 3.4%

7 Diabetes 2.7% Accidents 1.9%

8 Hypertension 1.7% Hypertension 1.9%

9 Suicide 1.5% Drug-related 1.7%

Alzheimer’s Nephrosis 1.4% 10 diseases 1.5%

Source: NYC DOHMH Bureau of Vital Statistics, 2014 cited in in Mortality among Chinese New Yorkers, New York City Department of Health and Mental Hygiene (June 2017)

26 Figure 7. Unhealthy Scorecard: Brooklyn and Manhattan

Among the 52% who say they do NOT smoke: • Only 26% live in Manhattan • Only 27% live in Brooklyn versus nearly 50% in Queens

In addition, among the 43% of Chinese New Yorkers who say they watch their diet carefully: • Only 20% live in Brooklyn versus 40% in Queens and Manhattan

Source: SOMOS Health Survey of Chinese New Yorkers

27 28 MENTAL ILLNESS WE ARE DEPRESSED

Mental illnesses are not only disabling, but also widespread. coupled with unique challenges of being Chinese, such as Similar to New York City’s overall levels, over 10% of Chinese meeting expectations of immigrant parents, feeling socially New Yorkers in the SOMOS citywide survey say they suffer accepted, and gaining self-worth, are all major reasons.18 from depression.14 In Flushing—the largest Chinese New York Yet, it is important to note that the number of US-born City neighborhood—suicide is the third cause of premature Chinese suffering from depression may be higher than their death.15 Respondents from SOMOS’ in-depth interviews foreign-born counterparts because they may be more willing attest that everyone in the community either personally to seek help and self-report their diagnoses. As doctors suffers from depression, knows someone with the condition, serving the Chinese community point out, mental illness or knows someone who has committed suicide. often goes undiagnosed among Chinese immigrants because And yet, for Chinese New Yorkers, it is the elephant in the doctors either lack the knowledge to screen for it or patients room. SOMOS interviewees explain that mental illness for the answer questions dishonestly.19 Chinese community is a subject that is rarely talked about Despite how grave and commonplace mental health issues publicly, out of fear of being ostracized by a community are, the API community in New York City only received where news spreads fast.16 But, as the interviewees explain, 0.2% of contract dollars issued by the New York City depression is a common outcome for immigrants as adapting Department of Health and Mental Hygiene from 2002 to a new cultural setting is overwhelming, grueling, and both to 2014.20 Adequate funding is required to give doctors, isolating and suffocating.17 nurses, community advocates, and pharmacists the cultural Depression also haunts US-born Chinese New Yorkers. training and resources they need to screen, treat, and build Among the survey respondents who say they’ve been acceptance among the community effectively. diagnosed with depression, 61% live in Manhattan and 61% are US-born ( Table 4). The pressures of living in the city “Our friend who suffered from depression committed suicide Table 4. Chinese Diagnosed with Depression, by Borough and Generation two weeks ago. He never went

Brooklyn Manhattan Queens to see a doctor. He said if you actually bring yourself to see a 9.6% 60.7% 29.7% doctor, that means you admit

1st Generation 1.5 Generation 2nd Generation+ that you are really sick. That Came to US as an adult Came to US as a youth Born in the US would be as terrible as being 11.3% 27.5% 61.2% involved in a scandal.”

Source: SOMOS Health Survey of Chinese New Yorkers —46 year old female, Williamsburg, Brooklyn

29 DIABETES WE ARE “SKINNY FAT”

Eight percent of Chinese New Yorkers surveyed in the SOMOS citywide poll report to have been diagnosed with diabetes, just below the city’s overall average of 11%.21 However, according to the US Department of Health and Human Services, Asian Americans have the highest percentage of undiagnosed cases of diabetes across racial/ethnic groups.22

Chinese doctors in New York City explain that Chinese patients are held to a standard of health that does not apply to them. While being overweight is typically a tell-tale sign of Type-2 diabetes, generally many Chinese have a smaller body frame. Chinese tend to have less muscle and more visceral fat around their organs—a main cause of Type-2 diabetes. Thus, many Chinese with a lower body mass index (BMI) do not recognize the need for a regular wellness check. Their body type even fools some doctors; many doctors do not think to ask their Chinese patients to take the requisite blood tests to detect diabetes.

HYPERTENSION OUR HEARTS ARE UNDER PRESSURE

Overall, Chinese Americans are at higher risk for hypertension. Nearly 20% of the survey respondents said they have been diagnosed with hypertension. Hypertension is the leading risk factor for heart disease and stroke—the second and third cause of death for Chinese New Yorkers.

Two key biological factors that contribute to their predisposition are their BMI and family history of hypertension. In general, Chinese have a higher percentage of body fat for a given BMI and their prevalence is higher if their parents had it. Social and cultural factors that contribute to hypertension are stress, high-salt diet, and lack of health literacy.23

30 HEPATITIS B IT’S IN OUR BLOOD

Asian Americans are disproportionately predisposed to hepatitis B (HBV) because it is more common in Asian countries. There are 1.2 to 2 million people in the infected with HBV, and Asian Americans comprise over half of the cases, despite making up only 6% of the total US population.24 In New York City alone, 91,587 people reported to have chronic HBV from 2014-2017. Sunset Park and Flushing are the top neighborhoods with the highest rates of newly reported HBV infection—the two most populous Chinese neighborhoods in the city. In addition, 53% of the pregnant women infected with HBV were from China— making it likely their child will have the virus since it can be transmitted from mother to child during or after pregnancy.25

Hepatitis B is the leading cause of liver cancer—which ranks third in the type of cancer plaguing Chinese New Yorkers. While HBV is a vaccine preventable disease, there are numerous reasons why many Chinese and other Asian Americans have not screened for it or have left it untreated. First, many immigrants who come to the US as adults do not come from a country in which the HBV vaccination is compulsory. In New York City, 95% with the disease are born outside the US. Second, much of it is due to language barriers; 85% of those in the city that have HBV need interpretation services. Third, symptoms are so mild that it often goes undetected. Finally, there is a cultural stigma attached to the condition.26

While many Asian Americans are born with the virus, due to risk factors that include injection drug use, sexual transmission, and other risky behaviors that increase contact with infected blood, HBV infection is often received as a personal failing. City-wide campaigns like “B Free NYC” (2004-2007) and “Be Certain” (2012) are raising awareness of HBV, decreasing stigma, and encouraging screening among at-risk communities.

31

CHALLENGES OF OUR OWN BARRIERS TO HEALTH 34 “I was called several weeks ago by my friend. His father was in the hospital. No one explained what the issues were. They called me to go there to figure out what’s going on. In the end [the man] got pneumonia but no one told him. You ask the doctor and nurse, everyone is busy. This is a nightmare for them.”

–David Zhang, MD

35 CHALLENGES OF OUR OWN BARRIERS TO HEALTH

Why do Chinese New Yorkers die from lung cancer, stroke transportation constraints, and thus reliant on relatives to and heart disease, diabetes, suicide, and other preventative accompany them. conditions? In this section, we unpack the core barriers to These obstacles often lead to negative emotions, specifically health for Chinese New Yorkers. distrust. The SOMOS citywide survey found that 45% of Chinese New Yorkers feel negatively about the healthcare LIMITED RESOURCES MAGNIFIES system. While 32% cited cost as the main source of OBSTACLES TO CARE frustration, many of the challenges are interrelated. For The usual headaches associated with going to the doctor’s instance, costly visits and confusing billing codes often office are exacerbated for Chinese New Yorkers and other are reasons for why they see healthcare hard to navigate immigrants of limited means. SOMOS’ citywide survey of through, especially insurance plans. This ultimately generates Chinese New Yorkers found that key barriers to care are distrust and suspicion ( Figure 9 ). Indeed, many Chinese affordability, language, transportation, and ability to take interviewed wondered whether doctors have outside time off from work( Figure 8 ). The challenge is compounded agendas when making diagnoses. for those who are less familiar with the process or have

Figure 8. Top Barriers Figure 9. Reasons for Negative Associations about the Healthcare System Cost 55% say the cost of healthcare stops them Cost 32% from visiting the doctor on a regular basis.

Hard to navigate through 25% Family Support rules and options say they need their children or someone 55% Insurance 23% they trust to attend doctor visits with them. related

Trust in general/ Time Off Work 11% not patient-centric 49% say they can’t take time off of work for doctor’s visits. Chinese community 9% related Transportation Not great/ 8% 44% say getting to and from the doctor’s inconsistent care office is difficult.

Source: SOMOS Health Survey of Chinese New Yorkers Source: SOMOS Health Survey of Chinese New Yorkers

36 Chinese living in Queens: In need of more accessible care

• Nearly HALF say transportation challenges deter them from seeing the doctor versus just 28% in Manhattan and 26% in Brooklyn • HALF rarely go to the doctor (no more than once a year) versus Chinese in Manhattan and Brooklyn who go more frequently • Over 75% have been diagnosed with a condition versus 59% in Manhattan and 65% in Brooklyn • Nearly 60% feel negatively about the healthcare system versus just 33% in Manhattan and 44% in Brooklyn

Source: SOMOS Health Survey of Chinese New Yorkers

37 LANGUAGE AND CULTURE ARE A MATTER OF LIFE AND DEATH

For Chinese New Yorkers, communication is the biggest barrier to care. 6 out of 10 Chinese New Yorkers have limited English proficiency( Figure 10 ). Compounding the challenge is health literacy. 50% of the SOMOS survey respondents report that they still do not understand medical terms “The relationship between a and explanations even if their doctor speaks their native primary care doctor and a patient language. Moreover, 54% of Chinese New Yorkers say that most healthcare providers do not share or understand is a business relationship.” their culture. — 67-year-old male, Bay Ridge, Brooklyn Even among native-born, English speakers, navigating the New York healthcare system and understanding medical terms can be intimidating. But for the Chinese New Yorkers with language and cultural barriers, getting care can result in a distressing experience—from feeling disrespected, dealing with long delays before they find someone they can speak with, to not getting care in time. Language and culture can literally be a matter of life and death. their patients—having multiple offices in Lower Manhattan, Sunset Park, and the larger Flushing area, as well as keeping Fortunately, 70% of those surveyed in the SOMOS citywide long and weekend hours—the wait times can be too long.27 survey reported to have a primary care doctor who speaks This can deter patients from having a relationship with a their Chinese dialect. Among the 30% that do not, half wish Chinese-speaking primary care doctor. they did ( Figure 11 ). According to Chinese-speaking doctors, a potential reason why such individuals have not found a More still, according to the Chinese-speaking physicians, the doctor to meet their language needs is that many patients impact of language and cultural barriers is heavily felt once are illiterate or do not speak the main Chinese dialects of Chinese patients need the help of a specialist or need to Mandarin or Cantonese. Moreover, while many Chinese- go to the hospital. As Dr. Michael Li, a physician serving the speaking doctors go to great lengths to accommodate Flushing area, explains, “Who is going to take care of them? Most doctors don’t speak their language. They do provide translation, but translation is not enough; it’s a culture thing. So they get lost.” 28

Doctors serving the Chinese community universally agree that lack of culturally-competent hospital staff and social workers along with poor access to Chinese-speaking specialists, such as psychologists, surgeons, and speech therapists, are fundamental barriers for Chinese in New York.29

38 Figure 10. Language Proficiency of Chinese New Yorkers, 2017

Bilingual 26%

English only 13%

LEP 61%

Source: US Census Bureau, 2017 American Community Survey, 1-Year Estimates, Chinese only or in combination, New York City Limits

Figure 11. Language Used with Primary Care Doctor

Does your primary care doctor speak Chinese?

Yes, Cantonese 20% Yes, other Chinese dialect 7%

7 out of 10 Chinese in New York have a primary care doctor who speaks Chinese

Among those that don’t, nearly 50% preferred they did

No Yes, Mandarin 30% 42%

Source: SOMOS Health Survey of Chinese New Yorkers

39 40 “Every patient is different. It depends on their background, their culture, how long they’ve been in America, their education level. For new immigrants, they are not familiar with the New York healthcare system. Some don’t even speak Mandarin or Cantonese, so even if the doctor is Chinese, you need a translator.”

— Rui Er Teng, MD

41 IGNORANCE IS NOT BLISS Figure 12: Reasons for Avoiding Professional Care

Providing deeper and more culturally-nuanced insights, SOMOS’ four in-home interviews with Chinese New Yorkers— all of whom are immigrant, low-income, and dependent—identify four core reasons for opting out of seeing a doctor ( Figure 12 ):

Belief that a visit will 1. Belief that a doctor will find something wrong lead to more diagnoses no matter what 2. Distrust in Western medical practices 3. Not wanting official news of a diagnosis 4. Stigma associated with certain diagnoses

According to the Chinese New Yorkers interviewed, everyone Belief that prescription medications are too strong and in the Chinese community knows that “one’s just asking for will create other health issues it” when they visit their doctor. They believe that doctors will find something wrong in order to get paid. Others avoid formal care because they view the drugs that US doctors prescribe to be ultimately harmful to their bodies. Many eastern cultures believe that pain is a result of being off-balance and thus drugs intended to address a condition in isolation will further aggravate the body.30 Some simply don’t want to hear officially that they are sick. Abstain from seeking medical care/exams in fear The interviewees also attest that social stigma associated of being told of illnesses with diagnoses is a major deterrence for Chinese New Yorkers in seeking care. From disclosing symptoms to doctors to fear that such news would spread, diagnoses like mental illness, women’s health issues and even diabetes are considered off-limits because they are viewed as signs of personal weakness.31 Such diagnoses are considered taboo in other cultures too—even within mainstream America— Not disclosing illnesses to but when a community is close-knit and cultural beliefs are avoid being stigmatized tightly held, stigma is anathema. Source: SOMOS in-depth interviews of Chinese New Yorkers

42 “I am so healthy right now why do I need to go see a doctor? They will find out that you are sick as soon as you do those exams but otherwise you are just fine. That’s usually how it goes.”

—67-year-old male, Bay Ridge, Brooklyn

43 44 THE CULTURAL LANGUAGE OF HEALTH “The challenge for the patient is when they see someone who doesn’t understand their culture, who doesn’t understand their language, they aren’t going to get good service or care. How can you ask a patient to see a doctor who does not understand them?”

— Ming Zhu, MD

46 47 THE CULTURAL LANGUAGE OF HEALTH

To understand how cultural factors play a role in the health doctors’ recommendations because it contradicts their own of Chinese New Yorkers, this section focuses on the insights practices. Such cases can be very dangerous as doctors derived from SOMOS’ focus group with 10 doctors serving may not be aware of possible drug interactions. Moreover, the city’s Chinese communities, four in-home interviews some Chinese patients put more faith in TCM, consuming with Chinese immigrant New Yorkers, and existing research. in-language programs that discuss the latest trends in TCM, Findings reveal that Chinese cultural perspectives and without doing further research about proper application, traditions can adversely impact Chinese New Yorkers’ safety issues, or efficacy. Indeed, regulations and knowledge health in unintentional ways. on herbal medicine are often unstandardized and insufficient. Many herbal products, for example, have heavy metals, INHARMONIOUS MEDICAL PRACTICES are unlicensed, and do not have labels that warn of potential contraindications.33 Many Chinese patients tend to equally utilize Western and traditional Chinese medicine (TCM) practices: 65% surveyed Figure 13. Utilization of Primary Care Doctor versus in the SOMOS poll say they go to their primary care doctor Traditional Medicine and nearly 60% say they practice TCM regularly ( Figure 13 ). Primary Doctor Frequency Based on the in-home interviews with Chinese New Yorkers, Never Often 2% Chinese patients believe that traditional remedies like 65% acupuncture, foot reflexology, cupping, and herbal medicine are a more “thorough cure” that provides more long-term benefits. Chinese patients will go to primary care doctors for prescription drugs like antibiotics or to treat more Rarely 33% serious conditions. This in itself is not a problem; in fact, such practice can often be beneficial. Many doctors who Traditional Practice Frequency serve Chinese communities are well versed in traditional Never Often methods and incorporate them into their own practice.32 15% 57%

However, tradition can at times get in the way of proper medical attention. According to the SOMOS Doctors’ Focus Group, problems arise when patients believe they can self- Rarely medicate with TCM as a workaround to formal care, do not 28% disclose what they do at home, or do not comply with their Source: SOMOS Health Survey of Chinese New Yorkers

48 “I’ll take traditional Chinese medicine when I get a cold. It’s a more thorough cure. Acupuncture provides long- term benefits, not just to cure the superficial symptoms. I will go to see a primary doctor when I feel I need antibiotics.”

–43-year-old female, Coney Island, Brooklyn

49 UNHEALTHY CULTURAL HABITS

The SOMOS citywide survey found that only 43% of Chinese New Yorkers watch their diet carefully. However, a core concern for the doctors serving the Chinese community is that their patients steadfastly believe their diet to be healthy enough. According to the Chinese-speaking doctors in New York, habits as innocuous as eating rice can be a silent killer for the community. Many Chinese people view white rice as a vital source of energy—and more importantly, a centerpiece of their culture. Indeed, instead of saying “hello,” many greet others with the question, “have you eaten rice?” This context helps to explain why doctors serving the community have a challenging time getting diabetic Chinese patients to reduce white rice intake to control their condition. Their patients see it as antithetical to their culture and thus impossible to implement.34 While Chinese physicians are seeing some of their patients switching to brown rice or other alternatives, change is slow when it involves something deeply embedded in Chinese culture.

As well-meaning as they are, Chinese grandparents can also be a source of unhealthy cultural habits in the community. According to a study that evaluated Chinese pediatric patients at a community health center in New York City, care provided by grandparents is associated with childhood obesity in Chinese families. Grandparents often use meals as a way to pass down cultural traditions, express affection, and a means to feel useful in the family. Children are encouraged to eat large portions and often, which have resulted in higher rates of childhood obesity and an average BMI that is greater than 85th percentile.35

Smoking is another unhealthy cultural habit. Based on the New York City Department of Health and Mental Hygiene, Chinese men living in New York are almost seven times more likely than their female counterparts to be smokers. This is a rare case where stigma produces positive benefits; women in China are judged for smoking. Meanwhile, men in China (wherein 60% smoke) consider smoking a cultural norm, which persists in New York City.36

50 51 “You cannot say that they’re specific symptoms. Yet another reason goes back to health literacy; Chinese New Yorkers may be unfamiliar with the depressed because they don’t diagnosis, but pain is understood. For conditions that have want to hear that. You basically yet to show negative impact, patients may continue habits have to communicate with them that exacerbate the underlying problem. through their symptoms first. Doctors serving Chinese patients urge other doctors, pharmacists, nurses, and health practitioners to strategize If you know that their insomnia ways to best communicate their Chinese patients’ diagnoses, is stemming from depression, so that treatment is taken seriously. It starts with building trust through an understanding of Chinese language, and you have to tell them that the more importantly, Chinese culture. medication will calm them down and help them sleep better at night.”

—Ming Zhu, MD Table 5. Current Health Concerns

Rank Chinese in NY

DIFFERENT POVS: 1 Pain 18.4% SYMPTOM VERSUS DIAGNOSIS 2 Diabetes 16.3% Results from the citywide SOMOS poll and the focus group with the doctors revealed yet another communication 3 High blood pressure/Hypertension 14.5% challenge: Chinese patients tend to focus on the symptoms while doctors focus on the diagnosis. When the respondents 4 Cost of healthcare with aging 12.8% from the SOMOS poll were asked if they were concerned about any health conditions, “pain” was the most frequent 5 Heart disease 11.2% open-ended answer ( Table 5 ). 6 High cholesterol 10.9% According to the Chinese-speaking doctors, a reason for the focus on symptoms is that they may not like the label 7 Cancer 6.6% of the diagnosis itself. As Dr. Ming Zhu, a Flushing-based 8 Allergies 6.1% physician, explains, “You cannot say that they’re depressed because they don’t want to hear that. You basically have to 9 Digestive problems 4.4% communicate with them through their symptoms first.” Even if the diagnosis may not have the stain of stigma, Chinese 10 Overweight/Obesity 4.0% patients may want to minimize the issue by focusing on the

Source: SOMOS Health Survey of Chinese New Yorkers, open-verbatim comments

52 53 54 UNTANGLING THE KNOT LEARNING FROM POSITIVE INDICATORS OF GOOD HEALTH UNTANGLING THE KNOT LEARNING FROM POSITIVE INDICATORS OF GOOD HEALTH

While our research identifies major health barriers facing “I’d give the healthcare system a Chinese New Yorkers and the need for more culturally- relevant health resources, there are also many positive 75-80 out of 100. A good system findings. Consistent with US Census data, the SOMOS overall, but with holes.” citywide survey found that over 90% of Chinese New Yorkers —48-year-old female, Williamsburg, Brooklyn have health insurance—nearly 50% through government- funded insurance. Moreover, 70% have a Chinese-speaking doctor and 65% report visiting their primary care doctor “often.” Moreover, half the Chinese New Yorkers have a positive view of the healthcare system ( Figure 14 ).

There’s a strong correlation between satisfaction and access to more health resources. Among the Chinese surveyed who Figure 14. Feelings about the Healthcare System feel positively about their healthcare:

Mixed Emotions • Two-thirds have a Chinese-speaking doctor 4% • 63% have government-funded healthcare via Medicaid or NY State of Health/Affordable Care Act • Nearly 70% live in Manhattan, home to established Chinese community health centers, social service organizations, and Chinese adult schools ( Figure 15 ) Feelings about the Healthcare System

Positve Emotions Negative Emotions 51% 45%

Source: SOMOS Health Survey of Chinese New Yorkers

56 Figure 15. Feelings Associated with the Figure 16. Sources of Health Information Healthcare System, By Borough

Doctor’s office 56% Positive Negative Websites 54%

Friends/Family 41%

32.7% Social media 31%

44.1% 46.6% Health clinic 28% 57.7% Television 23%

Newspaper/Print Publications 21%

Insurance provider 15%

Social worker 11%

67.3% Radio 8% 55.9% 53.4% Community organizations 8% 42.3% Other 4%

Don’t know where to get 3%

Queens Manhattan Brooklyn Other

Source: SOMOS Health Survey of Chinese New Yorkers Source SOMOS Health Survey of Chinese New Yorkers

REACHING OUT IN OUR LANGUAGE AND IN OUR CULTURE Figure 17. Chinese Media Consumption

Community outreach plays a critical role in the utilization of healthcare services. The SOMOS citywide poll finds that Chinese New Yorkers get their health information through 5-10 hours a week 1-4 hours a week 34% 29% community centers, such as Chinese adult schools and health clinics ( Figure 16 ). According to their doctors, their patients learn about public health insurance and Chinese-speaking doctors through referrals from friends and family.

Outreach via Chinese native media channels is also invaluable. According to the SOMOS citywide survey, over 80% of Chinese New Yorkers consume Chinese-language media 10+ hours Never ( Figure 17 ). Interview respondents expressed enthusiasm 20% 17% for information on WeChat, a native social media app with near universal penetration among Chinese-speakers globally.37 SOMOS has begun to create a robust application within WeChat to place culturally-relevant, informative health Source SOMOS Health Survey of Chinese New Yorkers content within reach.

57

UNDERSTOOD CREATING A CULTURALLY-FLUENT HEALTH INFRASTRUCTURE UNDERSTOOD CREATING A CULTURALLY-FLUENT HEALTH INFRASTRUCTURE

With a population of over 800,000, the greater New FIRST & FOREMOST York metropolitan area is home to the largest Chinese Extend DSRIP and continue building a community outside of Asia. The rich history of Chinese in patient-centric system that fosters better New York spans over a century and the vibrant community healthcare and lowers costs. today continues to grow at an unprecedented rate of The obstacles that prevent Chinese New Yorkers from nearly 50%. seeking regular care stem in large part from communication. However, the results from this study demonstrate that the Language and cultural barriers keep them from being health of Chinese New Yorkers is uneven—with some thriving, able to communicate with their doctors, understand their some underserved and misunderstood, and a majority doctor’s prescriptions, and feel culturally supported. There is experiencing both. Chinese New Yorkers’ health depends on also a significant unaddressed chasm between Chinese New having access to culturally-competent care, which is sorely Yorkers’ understanding of wellness—often influenced by lacking, leading to significant but surmountable barriers. Chinese customs and traditions—and healthcare—defined by Western practices. This gap fuels misunderstanding between Much of the urgency to create a culturally-fluent health Chinese patients and healthcare providers. Moreover, when infrastructure comes from the fact that ideal health healthcare practitioners cannot effectively communicate conditions for the Chinese community are in sight. with their patients why they need additional services, labs, The positive indicators offer lessons on how to further or appointments, it can lead to unresponsiveness improve and make this community a model of health. and noncompliance. We are confident that by taking the right steps, we can work towards a future where Chinese New Yorkers feel Persistent income inequality exacerbates these health empowered to improve their overall well-being. Looking challenges. In addition to not receiving culturally-competent ahead, it is our hope that policymakers will use this study care, Medicaid patients often receive inconsistent care. as a roadmap to create a stronger, healthier New York. The number of Chinese patients experiencing inconsistent We believe that the path to that goal runs through the care is vast: over 300,000 Chinese New Yorkers have city’s Chinese communities. publicly-funded insurance.38 The root of the problem is how traditional forms of delivery rewards providers for the So how do we get there? The following are policy volume of care, regardless of the outcomes. For Chinese recommendations that address the barriers revealed by New Yorkers with limited financial resources, time, English The State of Chinese Health in New York City: proficiency, family support, and access to transportation, the possibility of getting unsatisfactory care alone deters

60 them from setting up or following through with doctor appointments. This results in patients forgoing preventative care until health conditions worsen to the point of requiring emergency care or hospitalization—which certainly comes at great cost to the state. In this fee-for-service model, patients are far from being at the center of healthcare.

State-based solutions have started to chip away at this simmering crisis. Under New York State Governor Andrew Cuomo’s direction, a model called Delivery System Reform Incentive Payment ( DSRIP) has been transitioning all providers to a value-based-payment paradigm that pays on the basis of overall patient health results. Through the support of the DSRIP program, SOMOS—the only physician- led network to be designated as a Value Based Payment Innovator by the New York State Department of Health— has been at the forefront in New York City in making this change. In the four years since SOMOS launched, we have:

• Successfully reduced potentially preventable hospital readmissions by 25.7% • Reduced potentially preventable hospital admissions by 20.4% • Engaged with a total of 1.34 million patients annually through DSRIP projects 39

Such results have generated enormous savings to the state and taxpayers. Moreover, by holding providers accountable for the services they provide to their patients, DSRIP has encouraged a new model of care to emerge: total care. Total care takes into context all factors that impact patients’ health, including but not limited to cultural, linguistic, environmental, social, and economic factors. This results in helping lift the Chinese community, as well as other diverse, high-need communities with specific challenges that have never been met by the system.

For example, SOMOS has established a Patient-Centered Medical Home ( PCMH) program, a team-based, holistic

61 62 model of care led by primary care physicians (PCPs) are scalable and sustainable—bringing us to the point where whereby patients can expect to have access to physical, we can transition to a for-profit, value-based-payment mental, and social-related care from a range of healthcare delivery model post-DSRIP that other healthcare systems providers: PCPs, specialists, community health workers, can emulate. Currently, an extension of the program is pharmacists, nutritionists, social workers, and therapists. under consideration. PCMHs prioritizes treating patients with respect, dignity, SOMOS supports this policy development and has and compassion. This encourages patients to receive regular recommended a two-phased approach, tiered into and comprehensive care—preventing costly procedures and, one- and three-year increments. more importantly, creating a bond of trust between doctor and patient.

In addition, recognizing the role that primary care physicians SECOND Continue building a robust community play as trusted figures in their communities, SOMOS health worker program. launched the Neighborhood-Based Primary Care (NBPC) program, which restores the community leadership role of Chinese-speaking community health workers (CHW) play the family doctor. PCPs are often on the front lines, seeing a vital role in helping Chinese New Yorkers get insured, first-hand what ails their communities. NBPC empowers find their doctors, and get the support they need. CHWs PCPs to organize community task forces that can address are a part of the patients’ community and thus share the the social determinants of health that impact their patients’ same language, culture, and values. This allows CHWs to well-being, such as housing conditions, environmental issues, authentically connect with patients and serve as critical employment, safety, access to healthy food, and education. intermediaries between health providers and patients. CHWs make home visits, inform doctors and staff of factors Many in Chinese communities, especially immigrant that impact patients’ health, keep appointments, and families, tend to live in multigenerational households as update and increase access of health records. As SOMOS well as nearby extended family and friends. Thus, through President and long-serving doctor to the Chinese New York the NBPC model, the traditional family doctor can have a Community, Dr. Henry Chen, explained, a good number of positive impact on entire neighborhoods. The more the Chinese immigrants live in impoverished households—and New York City health system is integrated into a specific they largely go unnoticed. They live in homes where there way a community is culturally shaped, the more patients are as many as 10 adults eating and sleeping in a single room are able to receive care. In short, programs like the PCMH with limited ventilation.40 For them, having a CHW can save and NBPC are spearheading an inclusive, 360-degree their lives. approach to improving the health of whole communities. SOMOS has been actively expanding its network of CHWs in These early successes of the DSRIP program demonstrate the Bronx, Brooklyn, Queens, and Manhattan and improving the feasibility of a value-based-payment paradigm. More ways CHWs can coordinate with medical providers, primary importantly, healthcare organizations like SOMOS feel care teams, and community organizations to improve patient empowered to explore and implement ambitious programs outcomes. Based on SOMOS’ Access-to-Care metrics, the like PCMH and NBPC that aim to deliver holistic patient- return on investment from one CHW at one PCP office for centric care. But our job is far from done. With the renewal four weeks of focus on annual wellness visits is estimated to of the DSRIP program, we will ensure that these successes be $96,848.41 Continuing to build out, recruit, and train for

63 the CHW program is essential in establishing a vital lifeline FOURTH between healthcare providers and patients. Create partnerships with Chinese CBOs to improve nutrition in SOMOS strongly recommends greater public investment in Chinese communities. culturally-competent, in-language fluent community health workers to engage with hard-to-reach, infrequent patients. The study revealed that Chinese New Yorkers are not as healthy as they think they are. Many Chinese food staples include empty carbohydrates like white rice and high THIRD sodium dishes that lead to a variety of long-term and Firmly establish partnerships with chronic health complications—from diabetes to hypertension. community-based organizations (CBOs) By utilizing and coordinating with the city’s robust network for community outreach. of Chinese and immigrant-serving community organizations, The SOMOS citywide survey indicates a correlation between we can expand the footprint of Community-Supported satisfaction with the healthcare system and having access Agriculture (CSAs) markets, urban rooftop farms, and farmer’s to established API community-based organizations (CBOs). markets in food deserts where many Chinese New Yorkers, Indeed, New York City-based CBOs like the Asian American particularly those in Brooklyn, reside. Local lawmakers and Federation play an instrumental role in tracking the social elected officials can play a critical role to help forge these determinants of health that impact patients’ mental and partnerships in Chinese communities across the city. physical health and getting the resources to address such factors. As such, the SOMOS CBO Partnership Program has SOMOS recommends greater collaboration between been coordinating with CBOs to align objectives, increase healthcare providers and local community groups to expand health literacy in a culturally-relevant way, and better nutrition programs and increase access to healthy food understand the funding needs of our communities. CBOs options for low-income Chinese communities. form a critical part of the community task force envisioned under the Neighborhood-Based Primary Care program. Such FIFTH partnerships need to continue to ensure our collective efforts Increase funding on Chinese-focused are productive and deliver the means for our communities health education with an emphasis on to thrive. reaching young people.

SOMOS strongly recommends greater public investment Youth-focused, culturally-sensitive health education for and multi-agency support for healthcare networks and Chinese New Yorkers can make all the difference. For community-based organizations. healthcare providers and staff, this means having a deeper and more empathetic understanding of Chinese culture to better communicate diagnoses, combat persistent stigmas particularly around mental health, and offer useful health information that does not undermine their traditions. It is especially important to reach younger Chinese Americans in New York City to help overcome unhealthy habits that get passed down generationally and close the knowledge and cultural gap related to health.

64 Through SOMOS’ network of CHWs and partnerships with CBOs, we’ve been active in providing Chinese-centered health education programs through health fairs in their communities and schools. We’ve been translating and distributing Chinese-language health resources as well as creating online content that features their peers and informs them of relevant health topics. Ultimately, cultural competency and health literacy can alleviate the distrust and disengagement found between Chinese patients and healthcare staff, which can in turn, reduce disparities in healthcare and improve patient outcomes.

SOMOS strongly recommends and will urgently press for significantly enhanced funding for health education in all Chinese dialects (not just Mandarin and Cantonese) that can reach Chinese New Yorkers of all ages. Health literacy can combat the cultural stigmas and lack of awareness that permit persistent smoking, imbalanced diet and nutrition, and poor mental health. This is an area where the city can make an immediate difference, including among a younger generation born in this country.

Building a healthy Chinese New York by being in our patients’ communities, being culturally in-tune with our patients, reaching out to our patients, and empowering our patients has been SOMOS’ focus for the last four years. We’ve seen major progress—but there is more in store. Renewal of DSRIP will give us the runway to continue the momentum of creating a sustainable, scalable, and for-profit value-based-payment model of delivery. Together, we can truly revolutionize the healthcare system to one that truly puts patients at the center.

65 APPENDIX

METHODOLOGY

All research and fielding took place in the spring and summer one-on-one, in-home interviews with low-income/Medicaid- of 2019. eligible, Chinese-language dependent Chinese residents in New York were conducted on June 19-20, 2019. Interviews 1. SOMOS Citywide Chinese Health Survey: An online survey were conducted in Mandarin. Respondent details include: of 300 Chinese residents in New York City was conducted from May 30 through June 16, 2019. It is a representative • 69-year-old female from Hong Kong living in Chinatown, sample of the Chinese demographic profile in New York City Manhattan based on US Census Bureau 2017 American Community • 67-year-old male from China living in Bay Ridge, Survey Estimates. It has a margin of error + 6% with a Brooklyn confidence interval of 95%. Respondents were given the • 48-year-old male from Taiwan living in Williamsburg, option of answering the survey in English, Traditional Brooklyn Chinese, or Simplified Chinese. Respondent criteria included: • 43-year old female from China living in Coney Island, Brooklyn • Must be Chinese • A resident of New York City 4. Secondary Research: To ensure research is comprehensive • At least 65% foreign and insights are contextualized, we leveraged public information • 50/50 gender split from the US Census Bureau and existing research, such as • At least 55% of the sample must speak more Chinese data from the New York Department of Health and Mental than English or only Chinese Hygiene, Asian American Federation, and studies from • Must be 18+, at least 70% aged 35+ established academic institutions. See Endnotes for full list.

2. SOMOS Doctors’ Focus Group: To gain an understanding of the unique experiences, challenges, and potential solutions to providing quality care to Chinese patients, a focus group of 10 doctors serving the Chinese community in New York was conducted on April 15, 2019.

3. SOMOS In-depth Interviews of Chinese New Yorkers: To gain a nuanced understanding of the most vulnerable Chinese New Yorkers relating to access to healthcare, four

66 ENDNOTES

1. US Census Bureau, 2017 American Community Survey 1-Year Estimates for New York City Metropolitan Statistical Area (Chinese alone or in any combination); The US Census Bureau defines the New York Metropolitan Area as including New York City, Long Island, the Mid and Lower Hudson Valley, Newark, Jersey City, Paterson, Elizabeth, and Edison, Bridgeport, New Haven, Stamford, Waterbury, Norwalk, and Danbury.

2. US Census Bureau, 2017 American Community Survey 1-Year Estimates for New York City (Chinese alone or in any combination)

3. Stephanie Tudor, “Believe it or not, New York City has Nine Chinatowns” Eater New York (February 25, 2019); Lawrence A. McGlinn, “Beyond Chinatown: Dual Immigration and the Chinese Population of Metropolitan New York, 2000,” Middle States Geographer 35 (2002) 110-119; Ford Fessenden, et. al, “Then as Now –New York’s Shifting Ethnic Mosaic,” (January 22, 2011)

4. US Census Bureau, 2017 American Community Survey, 1-Year Estimates, New York City (Chinese alone or in combination and Asian alone or in combination)

5. New American Economy Research Fund, “The Transcontinental Railroad at 150: The Contributions of Chinese Immigrants and Chinese Americans” (May 7, 2019)

6. Asian American Federation, Analysis of City Government Funding to Social Service Organizations Serving the Asian American Community in New York City (May 2015)

7. Rekesh Kochhar and Anthony Cilluffo, “Income Inequality in the U.S. is rising most rapidly among Asians,” Pew Research Center (July 12, 2018)

8. SOMOS Doctors’ Focus Group (April 15, 2019)

9. Melonie Heron, “Deaths: Leading Causes for 2017,” National Vital Statistics Reports (June 24, 2019)

10. Wenhui Li, et. al, “Mortality among Chinese New Yorkers,” New York Department of Health and Mental Hygiene: Epi Data Brief, no. 91 (June 2017)

11. K. Hinterland K, et. al, “Community Health Profiles 2018: Brooklyn Community District 7: Sunset Park,” New York Department of Health and Mental Hygiene, vol. 31, no. 59 (2018); K. Hinterland K, et. al, “Community Health Profiles 2018: Manhattan Community District 3: Lower and Chinatown, New York Department of Health and Mental Hygiene, vol. 3, no. 59 (2018)

12. Liza King and Wen Qin Deng, “Health Disparities among Asian New Yorkers,” New York City Department of Health and Mental Hygiene: Epi Data Brief, no. 100 (March 2018)

13. Wenhui Li, et. al, “Mortality among Chinese New Yorkers,” New York Department of Health and Mental Hygiene: Epi Data Brief, no. 91 (June 2017)

67 14. Rugile Tuskeviciute, et. al, “Depression among New York City Adults,” NYC Vital Signs, Vol. 17, no. 2 (April 2018)

15. K. Hinterland K, et. al, “Community Health Profiles 2018, Queens Community District 7: Flushing and Whitestone,” New York Department of Health and Mental Hygiene, vol. 49, no. 59 (2018)

16. SOMOS In-depth Interviews with Chinese New Yorkers (June 19-20, 2019)

17. Ibid.

18. Jie Zhang, et. al, “Depression, anxiety, and suicidal ideation among Chinese Americans: a study of immigration-related factors.” The Journal of Nervous and Mental Disease, Vol. 201, no. 1 (January 2013): 17-22

19. SOMOS Doctors’ Focus Group (April 15, 2019)

20. Asian American Federation, Overcoming Challenges to Mental Health Services for Asian New Yorkers (October 2017); Asian American Federation, Asian American Seniors in New York City: An Updated Snapshot (August 2016)

21. Liza King and Wen Qin Deng, “Health Disparities among Asian New Yorkers,” New York City Department of Health and Mental Hygiene: Epi Data Brief, no. 100 (March 2018)

22. National Institutes of Health, “News Releases: More than half of Asian Americans with diabetes are undiagnosed,” US Department of Health & Human Services (September 8, 2015)

23. Mei-Lan Chen and Jie Hu, “Health disparities in Chinese Americans with hypertension: A review,” International Journal of Nursing Sciences 1, no. 3 (September 2014) 318-322

24. Asian Liver Center, “What is Hepatitis B?,” Stanford School of Medicine, accessed on August 3, 2019, http://med.stanford. edu/liver/education/whatishepb.html

25. New York City Department of Health and Mental Hygiene, Working toward a Hep Free NYC: Hepatitis A, B, and C in New York City, 2017 Annual Report (2018)

26. Ibid.

27. SOMOS Doctors’ Focus Group (April 15, 2019)

28. Ibid.

29. Ibid.

30. Kelvin Chan, et. al, “An Overview on Adverse Drug Reactions to Traditional Chinese Medicines,” British Journal of Clinical Pharmacology 80, no.4 (October 2015), 834-843

31. SOMOS In-depth Interviews with Chinese New Yorkers (June 19-20, 2019)

32. SOMOS Doctors’ Focus Group (April 15, 2019)

68 33. Ibid.

34. Ibid; Angela Yee Man Leung, et. al, “Health literacy issues in the care of Chinese American immigrants with diabetes: a qualitative study,” BMJ Open 4, no. 11 (November 2014)

35. Jennifer D. Lau, et. al, “The association of grandparent care with childhood overweight and obesity in Chinese American families,” Child Obesity 15, no. 1 (September 26, 2018)

36. Liza King and Wen Qin Deng, “Health Disparities among Asian New Yorkers,” New York City Department of Health and Mental Hygiene: Epi Data Brief, no. 100 (March 2018); Donald G. McNeil Jr., “New York Confronts Rampant Smoking among Chinese Men,” New York Times (June 22, 2018)

37. Dauxe Consulting, 2018 WeChat Data Report (January 30, 2019)

38. US Census Bureau, 2017 American Community Survey 1-Year Estimates for New York City (Chinese alone or in any combination)

39. “Data Release Update: DSRIP SOMOS PPA Performance Updates from Baseline,” New York State Department of Health, January 2020

40. SOMOS Doctors’ Focus Group (April 15, 2019)

41. SOMOS, “Community Health Work Innovation” < https://somoscommunitycare.org/community-health-work-innovation/>

69 70